Bleeding and ischaemic outcomes in patients treated with dual or triple antithrombotic therapy: systematic review and meta-analysis
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Bleeding and ischaemic outcomes in patients treated with dual or triple antithrombotic therapy: systematic review and meta-analysis. / Haller, Paul M; Sulzgruber, Patrick; Kaufmann, Christoph; Geelhoed, Bastiaan; Tamargo, Juan; Wassmann, Sven; Schnabel, Renate B; Westermann, Dirk; Huber, Kurt; Niessner, Alexander; Gremmel, Thomas.
in: EUR HEART J-CARD PHA, Jahrgang 5, Nr. 4, 01.10.2019, S. 226-236.Publikationen: SCORING: Beitrag in Fachzeitschrift/Zeitung › SCORING: Zeitschriftenaufsatz › Forschung › Begutachtung
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TY - JOUR
T1 - Bleeding and ischaemic outcomes in patients treated with dual or triple antithrombotic therapy: systematic review and meta-analysis
AU - Haller, Paul M
AU - Sulzgruber, Patrick
AU - Kaufmann, Christoph
AU - Geelhoed, Bastiaan
AU - Tamargo, Juan
AU - Wassmann, Sven
AU - Schnabel, Renate B
AU - Westermann, Dirk
AU - Huber, Kurt
AU - Niessner, Alexander
AU - Gremmel, Thomas
N1 - Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.
PY - 2019/10/1
Y1 - 2019/10/1
N2 - AIMS: The combination of oral anticoagulation with a P2Y12 inhibitor and aspirin in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is associated with a high bleeding risk. Dual antithrombotic therapy (DAT) with omission of aspirin is a promising option to reduce bleedings, but carries a yet unknown risk of ischaemic events. We therefore sought to systematically review and analyse randomized controlled trials investigating DAT vs. triple antithrombotic therapy (TAT) in patients with AF following PCI and/or acute coronary syndrome (ACS).METHODS AND RESULTS: We included four trials with overall 9317 patients (5039 DAT, 4278 TAT) in our analysis. Dual antithrombotic therapy was associated with a significant reduction in thrombolysis in myocardial infarction major bleeding [hazard ratio (HR) 0.52, 95% confidence interval (CI) 0.42-0.65; P = 0.0001], while the composite trial-defined ischaemic endpoint did not differ significantly between DAT and TAT (HR 0.98, 95% CI 0.79-1.22; P = 0.88). There was also no difference regarding the occurrence of myocardial infarction (MI; HR 1.16, 95% CI 0.92-1.46; P = 0.21) or stent thrombosis (HR 1.25, 95% CI 0.69-2.26; P = 0.46). Absolute numbers for MI were 131/4278 (3.1%) with TAT and 182/5039 (3.6%) with DAT, and for stent thrombosis 32/4278 (0.75%) and 52/5039 (1%), respectively. A post hoc power calculation based on the size and event rate of this meta-analysis revealed 80% power to detect a 37% and 100% increase in MI and stent thrombosis, respectively.CONCLUSION: Dual antithrombotic therapy significantly reduces bleedings compared with TAT and seems to have a similar effect in preventing ischaemic endpoints in AF patients post-PCI or ACS. Future investigations are needed to determine its applicability specifically in patients at high risk of ischaemic outcomes.
AB - AIMS: The combination of oral anticoagulation with a P2Y12 inhibitor and aspirin in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is associated with a high bleeding risk. Dual antithrombotic therapy (DAT) with omission of aspirin is a promising option to reduce bleedings, but carries a yet unknown risk of ischaemic events. We therefore sought to systematically review and analyse randomized controlled trials investigating DAT vs. triple antithrombotic therapy (TAT) in patients with AF following PCI and/or acute coronary syndrome (ACS).METHODS AND RESULTS: We included four trials with overall 9317 patients (5039 DAT, 4278 TAT) in our analysis. Dual antithrombotic therapy was associated with a significant reduction in thrombolysis in myocardial infarction major bleeding [hazard ratio (HR) 0.52, 95% confidence interval (CI) 0.42-0.65; P = 0.0001], while the composite trial-defined ischaemic endpoint did not differ significantly between DAT and TAT (HR 0.98, 95% CI 0.79-1.22; P = 0.88). There was also no difference regarding the occurrence of myocardial infarction (MI; HR 1.16, 95% CI 0.92-1.46; P = 0.21) or stent thrombosis (HR 1.25, 95% CI 0.69-2.26; P = 0.46). Absolute numbers for MI were 131/4278 (3.1%) with TAT and 182/5039 (3.6%) with DAT, and for stent thrombosis 32/4278 (0.75%) and 52/5039 (1%), respectively. A post hoc power calculation based on the size and event rate of this meta-analysis revealed 80% power to detect a 37% and 100% increase in MI and stent thrombosis, respectively.CONCLUSION: Dual antithrombotic therapy significantly reduces bleedings compared with TAT and seems to have a similar effect in preventing ischaemic endpoints in AF patients post-PCI or ACS. Future investigations are needed to determine its applicability specifically in patients at high risk of ischaemic outcomes.
KW - Acute Coronary Syndrome/diagnosis
KW - Anticoagulants/administration & dosage
KW - Atrial Fibrillation/diagnosis
KW - Coronary Artery Disease/diagnosis
KW - Coronary Thrombosis/epidemiology
KW - Drug Therapy, Combination
KW - Female
KW - Fibrinolytic Agents/administration & dosage
KW - Hemorrhage/chemically induced
KW - Humans
KW - Male
KW - Myocardial Infarction/epidemiology
KW - Percutaneous Coronary Intervention/adverse effects
KW - Platelet Aggregation Inhibitors/administration & dosage
KW - Purinergic P2Y Receptor Antagonists/administration & dosage
KW - Randomized Controlled Trials as Topic
KW - Risk Assessment
KW - Risk Factors
KW - Stents
KW - Treatment Outcome
U2 - 10.1093/ehjcvp/pvz021
DO - 10.1093/ehjcvp/pvz021
M3 - SCORING: Journal article
C2 - 31198930
VL - 5
SP - 226
EP - 236
JO - EUR HEART J-CARD PHA
JF - EUR HEART J-CARD PHA
SN - 2055-6837
IS - 4
ER -